2003, 06-04 General Facilities ChargeCSG 4LQ'JUT 13 (cook ��43°v.5
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UTILITIES DIVISION
N. Bruce Rawls, P.E., Utilities Director
GENERAL FACILITIES CHARGE (GFC)
PAYMENT OPTION SELECTION RECORD
PLEASE NOTE:. Form must be filled out accurately and in its entirety, and signed, ora permit will not be issued.
410 5
A DIVISION OF THE PUBLIC WORKS DEPARTMENT
Date:
Plat Name: l J910 RA f -A 7Czj I t4P Lot No(s): 7
Block No(s):
Site Address(es): %0S Parcel No(s):
Owner Name:
OR, Builder Name:
PRINT Owner's Name
Payment Option Selected (Check One):
1. (
2. (
3. ) GFC payment in 24 equal monthly payments upon establishment of Sewer Billing Account.
31. rA4
6. it -0
GFC payment received at issuance of Sewer Connection Permit by
PR/NT Builder's Name
) GFC to be paid at closing, at the GFC rate in effect at the time of closing.
" moi" �O�LL�Aon
vision of Utilities
Complete one of the following statements.
a. Owner's Statement: 1,
, understand that I will be
billed for the applicable GFC amount in 24 monthly installments. The monthly GFC installments will be added
to my monthly sewer service charges.
b. Builder's Statement: I, , understand that because I
am selecting this option for payment of the GFC, that the purchaser of the home will be responsible for payment
of the applicable GFC in 24 equal monthly installments. I agree to formally disclose to potential buyers of the
property that the GFC charges will be added to the monthly sewer service billings as soon as billing
commences.
. Special Conditions: ( ) No ( ) Yes — See Reverse Side of Form
Cri
Owner's or Builder's Signature Date
Spokane County, Division of Utilities GFC Payment Option Form, Revised 11/01/01
1026 W. Broadway • Spokane, WA 99260.-0430 • (509) 477-3604 FAX: (509) 477-4715 TDD: (509) 477-7133